Women and Cardiovascular Disease

Author: Elena M. Umland, PharmD, CDE

IntroductionCardiovascular disease (CVD) in women has been brought to the attention of the public more often and in increasingly greater detail over the past decade. Epidemiologic data increasingly illustrate the gravity of this problem?perhaps an even greater one in women than in men. In addition, and as a result of these epidemiologic data, attention has been brought to the lack of studies evaluating pharmacologic and nonpharmacologic interventions in CVD in women. Overall, the past 2 decades have seen more treatment successes relative to atherosclerotic events in men than in women.1 This difference may stem from the lack of studies in women and/or from the lax attitude in evaluating and aggressively treating women.

The purposes of this article are as follows: (1) to present some of the available epidemiologic data relative to CVD in women; (2) to identify the risk factors and, where the information is available, to note how they differ from the risk factors used in estimating CVD risk in males; and (3) to list recommendations for reducing CVD risk in women.

Epidemiologic DataIn 2000, CVD claimed 945,836 lives in the United States. Of these lives, more than half (505,661) were women.2 CVD is the leading cause of death among all races of women in the United States, surpassing and in some cases doubling the rates of deaths observed secondary to all cancers combined.2 Among the women who died suddenly because of CVD, 63% did not experience previous symptoms. Furthermore, 38% of women (vs 25% of men) with a recognized myocardial infarction will die within 1 year of the initial event.2

CVD Risk Factors in WomenRisk factors for CVD in women are similar to those for men. However, certain lipoproteins?notably triglycer-ides (TG) and high-density lipoprotein (HDL)?and disease states such as diabetes mellitus (DM) may have a larger impact on CVD risk in women than they do in men (Table 1).

Risk factors for CVD in women include lifestyle factors that can be modified in patients who are motivated and encouraged to do so. These factors include cigarette smoking, lack of physical activity, overweight/obesity, and highly stressful psychosocial interactions. Specifically, cigarette smoking is the leading preventable cause of CVD in women.4 Compared with a non-smoker, if a woman smokes 1 to 14 cigarettes a day, her risk of developing CVD is 3-fold higher. If a woman smokes >14 cigarettes per day, her risk of developing CVD is 5.5-fold higher than her nonsmoking counterpart.3 Other risk factors that can be improved by lifestyle modifications, with or without the addition of drug therapy, include DM, hypertension, and dyslipi-demia (increased TG and low-density lipoprotein [LDL] levels and reduced HDL levels; Table 2).

Ways to Reduce CVD Risk in WomenClearly, one can see the relative increase in CVD risk in women associated with the specific risk factors listed above. The primary means of reducing risk is lifestyle modification. In cases, however, of increased risk despite adequate lifestyle modifications, or in patients for whom lifestyle modifications are not enough to help them reach their treatment goals, drug therapy should be considered.

Drug therapy to reduce CVD risk in female patients has not been employed to its maximal extent. As mentioned above, there has been a lack of studies evaluating gender-specific differences in response to antihypertensive and lipid-lowering drugs as well as aspirin. Some large studies that have included populations of women (albeit not a large portion of the overall study population) have provided enough data to support aggressive interventions to reduce CVD risk. An area of study has been the use of antihypertensives. In a trial evaluating systolic hypertension in the elderly, 57% of the patients included were female.5 This trial demonstrated a 25% reduction in CVD risk and a 36% reduction in stroke risk in patients treated with antihypertensive therapy.

Trials evaluating the statins that have included women have, in some cases, illustrated greater CVD risk reduction in women treated with these lipid-lowering drugs, compared with men treated.6 Furthermore, the largest trial relative to the number of women included (5082) showed comparable risk reduction in women treated with 40 mg/day of pravastatin, compared with treated men.7 These results make the case for equally aggressive management of hyperlipidemia in women as in men. Other factors to consider relative to lipid management in women include TG and HDL levels. In this population of patients, the use of fibric acid derivatives and niacin should be considered. Further research relative to the impact that these 2 classes of drugs have on CVD risk in women is warranted, especially given the relationship between TG and HDL in women and CVD.

It is also recommended that aspirin be employed to reduce CVD risk in women. The US Preventive Task Force recommends 75 to 160 mg of aspirin daily in men and women with a 10-year risk of developing CVD that is 10%.8

ConclusionCVD is the leading cause of death in women in the United States. Knowledge of the risk factors associated with its development and increasing knowledge about how some of these risk factors differ between men and women are crucial to reducing CVD incidence in women. Pharmacists are in a unique position?given their continued, ongoing contact with patients?to provide patients with education regarding risk factor management and the important role that adherence to med-ication(s) plays in reducing overall CVD risk.

An increase in high-density lipoprotein (HDL) cholesterol correlates with a larger reduction in CVD in women, compared with men. A 1-mg/dL increase in HDL cholesterol is associated with a 3% reduction in CVD in women and a 2% reduction in men.